This Memorandum of Understanding Is Between YOUR LOCAL PUBLIC HEALTH AGENCY and ENTITY

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This Memorandum of Understanding is between YOUR LOCAL PUBLIC HEALTH AGENCY and ENTITY.

WHEREAS, the LOCAL County Board of Health, acting through the LOCALPublic Health Department, has jurisdiction over all public health matters within JURISDICTION; and

WHEREAS, when a local or a National Security or Peacetime Emergency is declared under STATE Statutes, Chapter 12,LOCAL PUBLIC HEALTH AGENCYwill be responsible, as appropriate, for prophylaxis of residents and visitors in JURISDICTION; and

WHEREAS, ENTITY is capable of receiving and distributing medical countermeasures to their population, i.e., staff and members of their households, residents/guests, during a declared emergency; and

WHEREAS, LOCAL PUBLIC HEALTH AGENCY will provide needed medical countermeasures to ENTITY; and

WHEREAS, pursuant to STATE Stat. §144.4198 upon a determination by the STATECommissioner of Public Health (“Commissioner”) that a pandemic influenza, other life-threatening disease, or terrorist, accidental, or natural event requires urgent treatment or prophylactic measures through the utilization of a Closed Point of Dispensing (“Closed POD”) location: and

WHEREAS, upon such a determination by the Commissioner Legend drugs may be dispensed or administered via a Closed POD according to a plan approved by the Commissioner or by local public health agencies and the medical protocol criteria established by the Commissioner; and

WHEREAS, ENTITY has agreed to act as a Closed POD,

Therefore, it is mutually agreed between the parties as follows:

1. ENTITYand LOCAL PUBLIC HEALTH AGENCYshall mutually support each other in planning for an emergency incident, including ENTITYproviding a contact person(s) to work with LOCAL PUBLIC HEALTH AGENCYto develop a plan for receiving and dispensing medical countermeasures at ENTITY’s facility including methods of notification, critical staff contact information, plan activation steps, and plans for storage and distribution of medical countermeasures.

1. LOCAL PUBLIC HEALTH AGENCY shall provide advance training to ENTITYstaff that will function in key positions in distributing medical countermeasures.

1. ENTITYshall provide appropriate personnel to be trained in advance to dispense medical countermeasures and agrees to update staff periodically with new information provided by LOCAL PUBLIC HEALTH AGENCY.

1. LOCAL PUBLIC HEALTH AGENCYshall provide electronic and/or hard copy of all forms and information sheets to be distributed prior to and during an event. ENTITYshall make all copies needed and provide all printed information for staff and their households and facility residents/guests.

1. LOCAL PUBLIC HEALTH AGENCY shall provide the proper standing orders and medical protocols as established by the Commissioner at the time of the event.

1. ENTITY shall provide to LOCAL PUBLIC HEALTH AGENCY the maximum potential number of staff and household, and facility residents/guests so that an adequate supply of medical countermeasures may be picked up by ENTITY upon activation of the emergency plan.

1. ENTITYshall provide any updates of its dispensing plan toLOCAL PUBLIC HEALTH AGENCY.

1. ENTITYshall conduct screening using a form authorized by the STATE Department of Health for all staff and their households, and facility residents/guests.

1. ENTITY shall provide one available staff to pick up medical countermeasures and instructions for staff and their households, and facility residents/guests.

1. ENTITYshall dispense medical countermeasures provided by LOCAL PUBLIC HEALTH AGENCYin accordance with the standing orders and medical protocolsestablished by the Commissioner.

1. ENTITY will only provide medical countermeasures to identified staff, households, and groups as outlined in its plan, and pursuant to STATE. Stat. §144.4198, subd. 1, may not provide medical countermeasures to the public.

1. ENTITY shall not charge individuals a monetary fee for providing or administering medical countermeasures.

1. ENTITY shall maintain an accurate record of the number of medical countermeasures distributed by ENTITYduring an event and provide documentation to LOCAL PUBLIC HEALTH AGENCYas requested.

1. ENTITY shall provide ongoing information to staff and their households, and facility residents/guests as directed by LOCAL PUBLIC HEALTH AGENCYduring an emergency.

1. ENTITY shall provide a climate-controlled, secure room to store medical countermeasures during an emergency.

1. ENTITYshall return any unused medication or materials to LOCAL PUBLIC HEALTH AGENCY upon conclusion of the emergency response as directed by LOCAL PUBLIC HEALTH AGENCY.

1. LOCAL PUBLIC HEALTH AGENCYshall provide ENTITYthe option to participate in periodic exercises to test plans for dispensing of medical countermeasures.

1. Confidentiality of all patient information will be maintained by both ENTITY and LOCAL PUBLIC HEALTH AGENCYin accordance with the Health Insurance Portability and Accountability Act to the extent applicable, the Minnesota Government Data Practices Act, and all other laws and regulations governing data and patient privacy.

1. In the event ENTITY determines that it will not act as a Closed POD, its staff and identified groups would not be able to receive medical countermeasures through a Closed POD.

1. This Memorandum of Understanding may only be modified in a writing signed by both parties.

1. This Memorandum of Understanding may be terminated by either party upon such notice as may be practicable.

LOCAL PUBLIC HEALTH AGENCYName of Entity

(Signature) (Signature)__

(Print Name) (Print Name)

(Title) (Title)

Dated:______Dated:______

Approved as to Form and Insurance:

Assistant County Attorney

Event